General rules for dental record keeping and preservation in the Nordic countries

When performing dental identification of an unknown individual, the forensic odontologist requires sufficient ante mortem data. Therefore, accurate and thorough dental record-keeping is essential. Most dental records today are digital, but other forms remain equally important. It is vital to gather all available dental records regardless of their quality as every piece of information can be valuable in the identification process.

The duty and regulations for dental record keeping is stated in Bekendtgørelse om autoriserede sundhedspersoners patientjournaler [8] and Vejledning om journalføring på det tandfaglige område in Denmark [9], Patientdatalagen (SFS 2008:355) and Socialstyrelsens föreskrifter och allmänna råd om journalföring och behandling av personuppgifter i hälso- och sjukvården (HSLF-FS 2016:40) in Sweden [10][11], Laki sosiaali- ja terveydenhuollon asiakastietojen käsittelystä 703/2023 in Finland [12], Helsepersonelloven § 39 in Norway [13] and in Lög um sjúkraskrár 55/2009 in Iceland [14]. All these regulations state that health professionals with a license, such as dentists and dental hygienists, are required to maintain patient records containing necessary information for providing safe and effective care. Dental records play a crucial role in forensic identification of the deceased. All Nordic countries maintain high standard of dental record-keeping, which are similar in many aspects. From a forensic point of view, the following are the most important: The record should include the patient’s full name, date of birth, and, if necessary, a protected identity code. Records must be clear, with standardized abbreviations, and all entries should be dated on the day of treatment. Diagnoses should be documented before treatment, supported by radiographic images or photographs when needed. Treatment details, including materials used, must be recorded. If referrals are made, the specialist’s contact information should be included. Ideally the dental chart (odontogram) is filled out at the first visit and updated continuously. Each entry must be attributed to the clinician responsible.

Radiographs and photographs are considered parts of the records and should be maintained accordingly. Radiographs must be labelled with the patient's name and the date of examination, and written interpretations of the radiographs should also be included in the journal. While study- and working models are not required to be part of the journal in all countries, they can be important for assessing treatment outcomes and should be kept after treatment. Due to storage issues, it may be practical to photograph or scan the models. If replaced with photographs, the photographs of the model become a part of the journal.

In Denmark, Sweden and Norway, dental records should be kept for ten years after the last entry [8][9][10][13]. In Finland, dental records must be kept for 12 years after death or 120 years after birth [12]. In Iceland, it is prohibited to dispose of dental records unless authorized under Article 24 of the Public Archives Act No.77/201 [15]. If dental records can no longer be stored with the dentist, they must be submitted to the National Archives of Iceland in a specific format to ensure that the records can be retrieved if requested [14][15].

Figur 2

Tooth notation systems

Different ways of notating tooth numbers may be subject for confusion when collecting ante mortem-data on victims from various countries, during for instance mass casualties. Figure 3 shows four tooth notation systems that is still commonly used internationally today. Unfortunately, efforts to try to standardize the way dentists annotate teeth has failed. The FDI (World Dental Federation)-system has been suggested by ISO as a standardized system that should be used worldwide [16] and is recommended by Interpol for DVI-work [7]. The FDI-system is used in most Nordic countries today. Nevertheless, in Denmark, the Victor Haderup system is still commonly used, while dentists in the US insists on using their Universal system and the Palmer system is still widely used in the UK. Other tooth numbering systems may also be found in old dental records, and notation systems may sometimes be customized by region, institution, or practitioner. When interpreting old dental records, dentists are advised to always look for a legend or dental chart if available in the dental record. If unsure, cross-reference with tooth diagrams such as the one presented in figure 3.

Figur 3

How can the police access dental records for use in identification of missing persons?

Access to dental records is regulated by strict laws and guidelines to ensure patient privacy and confidentiality. In all Nordic countries, police can request access to dental records to aid in the identification of missing persons [8][9][13][14][17][18][19]. The process involves contacting relatives to obtain information about the missing person’s dentist to access the records.

In Sweden, a government-funded dental subsidy system allows tracking of which dental clinics have provided dental care for a patient, as citizens over 20 years receive subsidies, while younger individuals receive free dental care [20][21]. The Swedish Social Insurance Agency (Försäkringskassan) is responsible for paying the subsidy for adults and therefore maintains records of dental visits, which the police can request information from when an identity is assumed [21]. In Denmark, when a patient has been treated at a dental clinic, the dentist's provider number and the patient's social security number will be connected. The police can therefore, by contacting the health authorities, locate the missing person's dentist. If the missing person is under the age of 21, the police can request the dental record through the public dental care. In Iceland, access to dental records whether through the national health insurance database or directly from dental practitioners requires consent from a relative according to article 15 in Lög um sjúkraskrár [14]. The Health Insurance of Iceland (Sjúkratryggingar Íslands) [22] maintains a database of dental treatment records as they cover part of the dental expenses for specific groups, including children under 18 years old, disabled individuals, and pensioners over the age of 67. For individuals outside these categories, the only available approach for the police is to contact the missing person’s relatives to determine whether they have information about the individual’s dentist. Old dental records are held by the National Archives of Iceland for preservation [15]. In Finland, dental care is provided by public and private sectors, and the availability of the dental records needs to be acquired from both. Finland is divided into 21 wellbeing services counties, which offer dental records from the public sector. Dental care in private practices is partially compensated by the Social insurance institution of Finland (KELA), which is thus able to point out which dental clinic in the private sector the missing person has attended. Through the record offices of both of these sectors the police request dental records. The National Healthcare Information System Services (Kanta-services) withholds a national patient information archive, however, neither the police nor forensic odontologists can access the Kanta-services after an individual is deceased [12]. In Norway, there is no national patient record or -register neither in the Public Dental Service (PDS), nor in private practices, so the police must conduct their own investigation to sort out who was the dentist of the missing person. Dental care in Norway is provided by the Public Dental Service in 15 counties to children, adolescents, young adults and certain groups, such as nursing home residents. If the police know which county the missing person lived in, they may contact the PDS in that county. Adults generally pay for their own treatment in private practices in Norway, but some specific clinical procedures may be partly compensated by The Norwegian Health Economics Administration (Helfo). Thus, the police may contact this department to get information about the dentist’s treatment, but in most cases tactical police work is necessary, such as asking relatives and friends, or locating bills from the dentist at the missing person’s home.

In all the Nordic countries, the request for ante mortem dental records comes from the police. Occasionally, the police find it difficult to locate these records. Identifying the public or private clinic, or the dentist who performed the treatment, can be time-consuming, especially in countries without a national register detailing which dental clinics have provided dental care to a patient. Another issue arises from the fact that when requesting dental records, the police have neither possibility nor qualification to evaluate if the record is complete. Therefore, as a conclusion to this paper, we include a list of the components of a dental record that forensic odontologists would like the police to be provided with when they request records of a missing person: 

• The dentist's name and contact information

• The name and personal identification number of the missing person

• All written dental records (from the first visit to the most recent visit to the dental clinic)

• All dental radiographs (either digital radiographs or original analogue radiographs). Note: Printouts of the radiographs usually have too low quality

• An odontogram (e.g., a screenshot from the digital patient record, if applicable)

• All clinical photographs

• Referrals of other health care providers

• All models, analogues or digital scans

• Relevant documents from the dental technician

• Any other information that could be valuable in the identification process

It is important to emphasize that forensic odontologists will not judge dentists based on their dental records and have neither desire nor obligation to report potential malpractice to the authorities. Our mandate is to conduct secure identification work, and to do that, we need adequate dental records.  

Summary and conclusion

The process of forensic dental identification relies significantly on the quality and accuracy of dental records, underscoring the need for standardized record-keeping practices across borders. The Nordic countries uphold high standards in dental record management and enforce similar government regulations for record keeping, providing a model for effective collaboration and regulatory alignment, which ensures streamlined forensic processes. The protection of patient privacy, along with efficient record access protocols, facilitates effective forensic investigations and highlights the importance of an integrated approach to dental identification practices.